Provider Demographics
NPI:1023698131
Name:ITANI, MOHAMAD IBRAHIM (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMAD
Middle Name:IBRAHIM
Last Name:ITANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 WELCH RD APT 211
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1922
Mailing Address - Country:US
Mailing Address - Phone:443-467-4149
Mailing Address - Fax:
Practice Address - Street 1:213 QUARRY RD RM 4510B
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1416
Practice Address - Country:US
Practice Address - Phone:650-723-5184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA195476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine